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Patient Education and Health Outcomes: Implications for Library Service* BY JOANNE GARD MARSHALL,t Librarian/Researcher Programme for Educational Development
R. BRIAN HAYNES, Associate Professor Department of Clinical Epidemiology and Biostatistics and Department of Medicine McMaster University Hamilton, Ontario, Canada L8N 3Z5 ABSTRACT Many librarians take an active role in patient education, for practical and ethical reasons; however, it is important to examine the effect of such activities on health outcomes. Although the rationale for patient education is that increased knowledge leads to a change in attitude that in turn affects behavior, studies have shown that this is not always true. Furthermore, other studies have shown that patient education programs by themselves have no lasting influence on patient compliance with therapy that has been linked to improved health. Librarians should examine a variety of reasons for their involvement in patient education activities. For librarians who accept improved patient compliance as a goal, specific recommendations based on literature review are made to help implement effective strategies.
THE ROLE of the librarian in patient education has changed dramatically during the last decade. Although the librarian once saw her role as being that of the guardian of the medical literature for the physician alone, more recent trends of interprofessionalism, consumerism, and patient advocacy have produced a new philosophy. Many "medical" libraries have become interdisciplinary "health sciences" libraries, serving a variety of members of the health care team. Moreover, both health sciences librarians and public librarians have examined their joint responsibilities to provide consumer health information [ 1]. A number of specialized, library-based health information services for the public at large [2,3] and for patients in particular [4] have emerged as well. *Based on a paper presented before the Forty-eighth IFLA General Conference, Montreal, Canada, August 25, 1982. Work on this paper was supported in part by a grant from the Rockefeller Foundation. tCurrently director of information services for The Palliative Care Foundation, 288 Bloor Street W., Toronto, Ontario, Canada M5S I V8. Bull. Med. Libr. Assoc. 71(3) July 1983
Librarians, as information specialists, often can save both patients and health professionals a great deal of time and effort by locating appropriate resources and by teaching appropriate informationseeking skills. Librarians have unique abilities and training in the selection, acquisition, and organization of materials that can be put to good use in patient education-related endeavors. Through their involvement in patient education activities, librarians have played a more direct role in patient care while demonstrating their ability to change with the times. EVALUATING PATIENT EDUCATION Despite the contributions librarians can make to patient education, it is important to examine the overall effect of patient education activities. We need to know whether patient education is effective and, just as important, whether it does any harm. Do patients actually live longer or get better faster as a result of our educational efforts? If so, are some educational strategies more effective than others? What can we measure to discover if educational activities are beneficial or harmful? The answers to these questions are of great importance to health policy-makers and planners who decide the future of various health care-related programs. Examining these questions can help us, as librarians interested in patient education, to apply our scarce resources where they will do the most good. There are many reasons for librarians to become involved in providing patient education, not the least of which is that patients and family members ask for such services. This, however, assumes that increased knowledge changes attitudes, which in turn affects behavior. In fact, behavior change can precede knowledge gain or be independent of knowledge level [5]. A recent study [6] examined
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the introduction of a pediatric health education booklet into a London group practice. The results showed that the families receiving the booklet had fewer home visits and fewer office visits; however, a follow-up study demonstrated that mothers who had received the booklet were no more knowledgeable about the treatment of the six symptoms mentioned therein than were mothers who had not received the booklet. Most of the mothers did report that they had consulted the booklet at some time during the year and 28% had consulted it in the three months before the interview. The authors concluded that patients may need a simple manual to refer to, rather than an educational program designed to increase their knowledge. Nevertheless, there are other possible explanations for this relationship, e.g., that patients interpreted the booklet as a rebuke for overusing services and thus cut down on appropriate use. PATIENT COMPLIANCE If knowledge gain is not sufficient to measure the effectiveness of patient education, what other measures can we use? Although it is legitimate to measure patient satisfaction with the educational materials or training they have received, it may be even more important to see if education makes patients more likely to follow physicians' advice. In fact, the medical community has generally considered education a tool to improve "patient compliance" with treatment. Although one might assume that a patient does not follow his physician's advice because he does not grasp the consequences of his actions, the relationship between health advice and the recipient's behavior has proved much more complicated. More than 250 factors have been related to compliance [7], ranging from the weather [8] to the use of safety lock
pill dispensers [9]. In the prevention and treatment of human illness, lack of compliance with advice undermines whatever benefit might accrue from treatment. In ambulatory settings, it has been demonstrated repeatedly that most persons fail to act on health advice, either to prevent illness or to treat acute or chronic disease [10]. For example, recent surveys showed that less than 30% of all hypertensive patients benefit from treatment through lack of compliance with medical advice [I1], despite convincing evidence that use of antihypertensive medication helps prevent premature death from stroke and heart attack [ 12]. Health care practitioners daily face evidence of low compliance with their recommendations and
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must contend with the consequences. Their inability to improve patients' adherence to medical regimens is an important source of physicians' dissatisfaction in their professional activities [13]. These circumstances create a dilemma for both the practitioner and the patient. On the one hand, efficacious treatments are prescribed; on the other, these treatments are not followed, for reasons both complex and poorly understood. There is yet another reason for considering patient compliance as a desirable outcome of educational activities. Some evidence indicates that noncompliers differ substantively from compliers in ways that are independent of the effects of the treatment. For example, men who did not take a placebo in a randomized, double-blind clinical trial of preventive therapies for coronary heart disease died at a rate almost twice that of men who complied with the placebo regimen [14]. This does not mean that noncompliance increases mortality, but that it may indicate other, more complex factors that can affect health. EDUCATIONAL STRATEGIES TO IMPROVE PATIENT COMPLIANCE A number of studies have evaluated educational approaches to improve patient compliance. Colcher and Bass [15] found significant improvements in both compliance and therapeutic outcome when therapists carefully instructed patients on the need to take all the tablets prescribed for a ten-day course of penicillin for streptococcal pharyngitis. In fact, this tactic was as successful therapeutically as giving patients a long-acting intramuscular injection of penicillin, a technique that obviates compliance problems. The results of this study, for compliance at least, are supported by others that have shown that written [16,17] and verbal [18] instructions greatly enhance short-term compliance. It seems from these reports that it is unnecessary to explain elaborately the nature of an illness and its treatment: a simple, clear statement that all the medication must be taken will suffice. Gaining cooperation with long-term treatment is, however, much more difficult. Several studies indicate that using single strategies to increase compliance does not work. These studies included four that tested approaches based on informing the patient about his illness and about the need to adhere to treatment [ 19-22]. None of these studies found any influence on treatment outcome; two found no influence on compliance [ 19,22]; one found improvement in one aspect of compliance but none in two others [211; and one found a substanBull. Med. Libr. Assoc. 71(3) July 1983
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tial increase in dropping out among patients who received educational pamphlets [20]. Although instruction is all that is needed to ensure compliance with short-term treatment, it is not sufficient for long-term therapy. Although instructing patients does not seem to result in long-lasting effects, instructing physicians on compliance management can produce enduring benefits for their patients. This was the finding of Inui et al. [23], in a study in which the resident and staff physicians of a teaching hospital's outpatient department attended tutorials on the relationship of the "health belief model" to compliance, and on practical methods to detect and improve low compliance. A most encouraging result of this study was that improvements in patient outcomes were sustained on reassessment some six months after the tutorials. This implies that the physicians continued to use their new "compliance skills," whereas other studies demonstrated a decrease in patient compliance to control-period levels once the compliance intervention was terminated [24,25]. A strategy that has received only limited testing to date but that seems to hold some promise, when combined with other methods, is the soliciting and encouraging of family support for the patient [21 ]. Group discussions also can improve compliance, when used with other methods [21,26]. In one study, home visits of patients were found to promote adherence to antihypertension therapy when instruction about hypertension and reminders and reinforcement of compliance were included [27]. Many of these studies suggest that the more attention is paid to the problem of following therapy as prescribed, the greater will adherence be. This general observation is underscored by the substantial success of a procedure called "contingency contracting" [20]. This involves negotiating with the patient, at each visit, a brief contract in which the patient agrees in writing to perform some act that will help him achieve the therapeutic goal. In return for successful completion of the task, the patient negotiates a multiple reward. A possible cause for the success of this maneuver is that the patient actively participates in his care rather than passively receives medical advice [28]. However, ongoing supervision from health care personnel seems essential to the long-term maintenance of compliance, even if the patient becomes an active agent in his medical management. IMPLICATIONS FOR LIBRARY SERVICE The studies reviewed here show that patient education (or, at least, knowledge per se) does not Bull. Med. Libr. Assoc. 71(3) July 1983
improve the cooperation of patients with long-term health regimens; instead, it seems that more complex approaches to improving patient compliance have been effective. Such programs have often included educational components; however, it remains to be seen whether such instruction independently contributes to the success of these multifaceted approaches. How these findings affect the library's role in patient education depends on the goal set by the library. If the goal is simply to respond to requests for health information, it may suffice to measure consumer satisfaction. Librarians have a duty to help users find information; by requesting specific information, the recipient assumes the responsibility to use that knowledge. It may well be that one of the librarian's most important functions is to provide information that will allow a patient to make an informed decision about his health care or to seek additional medical opinions. This is an advocacy role that may not always result in patient compliance, but which may still be considered appropriate. Consumers who seek out health information may also represent a special group for whom knowledge will make a difference in health behavior. It should be kept in mind that the findings reported here relate to programs in which patients were not necessarily self-motivated to seek out health information. If, on the other hand, the goal of the library's participation in patient education is to encourage compliant behavior that is likely to affect health outcome positively, the implications of this review provide some firm direction: 1. Librarians should work closely with other professionals to plan a multifaceted approach to patient compliance in long-term therapy, as the more complex approaches [20,21,26] have proved effective. 2. Because some studies [ 1 5-17] show that education improves compliance in short-term therapy, librarians should make every effort to ensure that such information is readily available. Examples include instructions for taking short-term medications or for procedures needed only temporarily. It may be possible to work with other departments, such as the pharmacy, in this area. 3. Because educating health professionals about compliance-improving strategies is even more effective than direct efforts with patients [23], librarians should support such efforts. 4. In keeping with study findings [21,26], librarians' efforts should be directed toward
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helping patients become active participants rather than passive recipients of medical advice. REFERENCES 1. Eakin D, Jackson SJ, Hannigan GG. Consumer health education: libraries as partners. Bull Med Libr Assoc 1980;68:220-9. 2. Gartenfeld E. The community health information network. Libr J 1978;103:1911-4. 3. Goodchild E. The CHIPS project: a health information network to serve the consumer. Bull Med Libr Assoc 1978;66:432-6. 4. Marshall JG, Neufeld VR. A randomized trial of librarian educational participation in clinical settings. J Med Educ 1981;56:409-16. 5. Green LW. Should health education abandon attitude change strategies? perspectives from recent research. Health Educ Monogr 1970;30:27-48. 6. Anderson JE, Morrell DC, Avery AJ, Watkins CJ. Evaluation of a patient educational manual. Br Med J 1980;281:924-6. 7. Haynes RB, Taylor DW, Sackett DL, eds. Compliance in health care. Baltimore: Johns Hopkins University Press, 1979:454-66. 8. Badgley RF, Furnal MA. Appointment breaking in a pediatric clinic. Yale J Biol Med 1961;34:11723. 9. Lane MF, Barbarite RV, Bergner L, Harris D. Child-resistant medicine containers: experience in the home. Am J Publ Health 1971;61:1861-8. 10. Sackett DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes RB, Taylor DW, Sackett DL, eds. Compliance in health care. Baltimore: Johns Hopkins University Press, 1979:11-23. 11. Haynes RB, Sackett DL, Taylor DW. Practical management of low compliance with antihypertensive therapy: a guide for the busy practitioner. Clin Invest Med 1979;1:175-80. 12. Hypertension Detection and Followup Program Cooperative Group. Five-year findings of the hypertension detection and followup program: I and II. JAMA 1979;242:2452-77. 13. Ort RS, Ford AB, Liske RE. The doctor-patient relationship as described by physicians and medical students. J Health Hum Behav 1964;5:2534. 14. The Coronary Drug Project Research Group. Influence of adherence to treatment and response
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of cholesterol on mortality in the Coronary Drug Project. N Engl J Med 1980;303:1038-41. Colcher IS, Bass JW. Penicillin treatment of streptococcal pharyngitis: a comparison of schedules and the role of specific counseling. JAMA 1972;222:657-9. Sharpe TR, Mikeal RL. Patient compliance with antibiotic regimens. Am J Hosp Pharm 1974; 31:479-84. Linkewich JA, Catalano RB, Flack HL. The effect of packaging and instruction on outpatient compliance with medication regimens. Drug Intell Clin Pharm 1974;8:10-5. Dickey FF, Mattar ME, Chukzik GM. Pharmacist counseling increases drug regimen compliance. Hospitals 1975;49:85-8. Sackett DL, Haynes RB, Gibson ES, et al. Randomized clinical trial of strategies for improving medication compliance in primary hypertension. Lancet 1975;1:1205-7. Swain MA, Steckel SB. Influencing adherence among hypertensives. Res Nurs Health 1981; 4:213-8. Levine DM, Green LW, Deeds SG, Chwalow J, Russell P, Finaly J. Health education for hypertensive patients. JAMA 1979;241:1700-3. Shepard DS, Foster SB, Stason WB, Solomon HS, McArdle PJ, Gallagher SS. Cost-effectiveness of interventions to improve compliance with antihypertensive therapy. Prev Med 1979;8:229. Inui T, Yourtee E, Williamson J. Improved outcomes in hypertension after physician tutorials. Ann Intern Med 1976;84:646-51. Wilber JA, Barrow JG. Hypertension: a community problem. Am J Med 1972;52:653-63. McKenney JM, Slining JM, Henderson HR, Devins D, Barr M. The effect of clinical pharmacy services on patients with essential hypertension. Circulation 1973;48:1104-11. Nessman DB, Carnahan JE, Nugent CA. Improving compliance: patient operated hypertension groups. Arch Intern Med 1980;140:1427-30. Wilber JA, Barrow JG. Reducing elevated blood pressure: experience found in community. Minn Med 1969;52:1303-5. Shulman BA. Active patient orientation and outcomes in hypertensive treatment. Med Care 1979;1 7:267-80.
Received September 1982; revision accepted March 1983.
Bull. Med. Libr. Assoc. 71(3) July 1983
